Drug Allergy

Drug Allergy: An Updated Practice Parameter These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology. Chief Editors Roland Solensky, MD, and David A. Khan, MD Workgroup Contributors I. Leonard Bernstein, MD; Gordon R. Bloomberg, MD; Mariana C. Castells, MD, PhD; Louis M. Mendelson, MD; and Michael E. Weiss, MD Task Force Reviewers David I. Bernstein, MD; Joann Blessing-Moore, MD; Linda Cox, MD; David M. Lang, MD; Richard A. Nicklas, MD; John Oppenheimer, MD; Jay M. Portnoy, MD; Christopher Randolph, MD; Diane E. Schuller, MD; Sheldon L. Spector, MD; Stephen Tilles, MD; and Dana Wallace, MD Reviewers Paul J. Dowling, MD – Kansas City, MO Mark Dykewicz, MD – Winston-Salem, NC Paul A. Greenberger, MD – Chicago, IL Eric M. Macy, MD – San Diego, CA Kathleen R. May MD – Cumberland, MD Myngoc T. Nguyen, MD – Piedmont, CA Lawrence B. Schwartz, MD, PhD – Richmond, VA TABLE OF CONTENTS Summary Statements of the Evidence-Based Commentary Preface Evidence-Based Commentary Glossary I. Introduction Executive Summary II. Definitions Algorithm for Disease Management of Drug Hyper- III. Classification of Immunologically Mediated Drug sensitivity Reactions Annotations for Disease Management of Drug Hyper- A. IgE-mediated reactions (Gell-Coombs type I) sensitivity B. Cytotoxic reactions (Gell-Coombs type II) C. Immune complex reactions (Gell-Coombs type III) D. Cell-mediated reactions (Gell-Coombs type IV) These parameters were developed by the Joint Task Force on Practice E. Miscellaneous syndromes Parameters, representing the American Academy of Allergy, Asthma and 1. Hypersensitivity vasculitis Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology. 2. Drug rash with eosinophilia and systemic symptoms The American Academy of Allergy, Asthma and Immunology (AAAAI) 3. Pulmonary drug hypersensitivity and the American College of Allergy, Asthma and Immunology (ACAAI) 4. Drug-induced lupus erythematosus have jointly accepted responsibility for establishing “Drug Allergy: An 5. Drug-induced granulomatous disease with or Updated Practice Parameter.” This is a complete and comprehensive document at the current time. The medical environment is a changing environ- without vasculitis ment, and not all recommendations will be appropriate for all patients. 6. Immunologic hepatitis Because this document incorporated the efforts of many participants, no 7. Blistering disorders single individual, including those who served on the Joint Task Force, is a. Erythema multiforme minor authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of b. Erythema multiforme major/Stevens-Johnson these practice parameters by the AAAAI or ACAAI should be directed to the syndrome Executive Offices of the AAAAI, the ACAAI, and the Joint Council of c. Toxic epidermal necrolysis Allergy, Asthma and Immunology. These parameters are not designed for 8. Serum sickness–like reactions associated with use by pharmaceutical companies in drug promotion. Reprint requests: Joint Council of Allergy, Asthma & Immunology, 50 specific cephalosporins N. Brockway St, #3-3, Palatine, IL 60067. 9. Immunologic nephropathy 273.e1 ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY F. Other classification systems for drug allergy U. Complementary medicines IV. Risk Factors V. Other agents V. Clinical Evaluation and Diagnosis of Drug Allergy A. History CONTRIBUTORS B. Physical examination The Joint Task Force has made a concerted effort to acknowl- C. General clinical tests edge all contributors to this parameter. If any contributors D. Specific tests have been excluded inadvertently, the Task Force will ensure E. Tissue diagnosis that appropriate recognition of such contributions is made VI. Management and Prevention of Drug Allergic subsequently. Reactions A. General CHIEF EDITORS B. Induction of drug tolerance Roland Solensky, MD C. Immunologic IgE induction of drug tolerance Division of Allergy and Immunology (drug desensitization) The Corvallis Clinic D. Immunologic non-IgE induction of drug tolerance Corvallis, Oregon for nonanaphylactic reactions David A. Khan, MD E. Pharmacologic induction of drug tolerance (eg, Professor of Medicine aspirin desensitization) Division of Allergy & Immunology F. Undefined induction of drug tolerance University of Texas Southwestern Medical Center G. Graded challenge Dallas, Texas VII. Specific Drugs A. ␤-Lactam antibiotics WORKGROUP CONTRIBUTORS 1. Penicillin I. Leonard Bernstein, MD 2. Ampicillin and amoxicillin Professor of Clinical Medicine 3. Cephalosporins University of Cincinnati College of Medicine 4. Cephalosporin administration to patients with a Cincinnati, Ohio history of penicillin allergy Gordon R. Bloomberg, MD 5. Penicillin administration to patients with a Associate Professor, Department of Pediatrics history of cephalosporin allergy Division of Allergy & Pulmonary Medicine 6. Monobactams (aztreonam) Washington University School of Medicine 7. Carbapenems Saint Louis, Missouri B. Non–␤-lactam antibiotics Mariana C. Castells, MD, PhD C. Antimycobacterial drugs Director, Desensitization Program D. Diabetes medications Associate Director, Allergy Immunology Training Program E. Cancer chemotherapeutic agents Brigham & Women’s Hospital F. Human immunodeficiency virus (HIV) medications Harvard Medical School G. Disease-modifying antirheumatic drugs (DMARDs) Boston, Massachusetts H. Immunomodulatory agents for autoimmune diseases Louis M. Mendelson, MD I. Modifying drugs for dermatologic diseases Clinical Professor J. Perioperative agents University of Connecticut K. Blood and blood products Partner, Connecticut Asthma & Allergy Center, LLC L. Opiates West Hartford, Connecticut M. Corticosteroids Michael E. Weiss, MD N. Protamine Clinical Professor of Medicine, O. Heparin University of Washington, School of Medicine P. Local anesthetics Seattle, Washington Q. Radiocontrast media (RCM) R. Aspirin and nonsteroidal anti-inflammatory drugs TASK FORCE REVIEWERS (NSAIDs) David I. Bernstein, MD S. Angiotensin-converting enzyme (ACE) inhibitors Department of Clinical Medicine, Division of Immunology T. Biologic modifiers University of Cincinnati College of Medicine 1. Cytokines Cincinnati, Ohio 2. Anti–TNF-␣ drugs Joann Blessing-Moore, MD 3. Monoclonal antibodies Department of Immunology 4. Omalizumab Stanford University Medical Center 5. Anticancer monoclonal antibodies Palo Alto, California VOLUME 105, OCTOBER, 2010 273.e2 Linda Cox, MD Acknowledgments Department of Medicine The Joint Task Force wishes to acknowledge the following Nova Southeastern University individuals who also contributed substantially to the creation Davie, Florida of this parameter: Erin Shae Johns, PhD, and Jessica Karle, David M. Lang, MD MS, for their immense help with formatting and restructuring Allergy/Immunology Section, Division of Medicine this document; Susan Grupe for providing key administrative Cleveland Clinic Foundation help to the contributors and reviewers of this parameter; and Cleveland, Ohio Brett Buchmiller, MD, for his assistance in creating the Richard A. Nicklas, MD algorithms in this parameter. Department of Medicine PREFACE George Washington Medical Center Washington, DC The objective of “Drug Allergy: An Updated Practice Param- John Oppenheimer, MD eter” is to improve the care of patients by providing the practicing physician with an evidence-based approach to the Department of Internal Medicine diagnosis and management of adverse drug reactions. This New Jersey Medical School document was developed by a Working Group under the Morristown, New Jersey aegis of the Joint Task Force on Practice Parameters, which Jay M. Portnoy, MD has published 26 practice parameters and updated parameters Section of Allergy, Asthma & Immunology for the field of allergy/immunology (these can be found The Children’s Mercy Hospital online at www.jcaai.org). The 3 national allergy and immu- University of Missouri-Kansas City School of Medicine nology societies—the American Academy of Allergy, Kansas City, Missouri Asthma and Immunology (AAAAI), the American College of Christopher Randolph, MD Allergy, Asthma and Immunology (ACAAI), and the Joint Center for Allergy, Asthma and Immunology Council of Allergy, Asthma and Immunology (JCAAI)— Yale Hospital have given the Joint Task Force the responsibility for both Waterbury, Connecticut creating new parameters and updating existing parameters. Diane E. Schuller, MD This parameter builds on “Disease Management of Drug Department of Pediatrics Hypersensitivity: A Practice Parameter,” which was pub- Pennsylvania State University lished in 1999 by the Joint Task Force on Practice Parame- Milton S. Hershey Medical College ters. It follows the same general format as that document, Hershey, Pennsylvania with some substantive changes reflecting advancements in Sheldon L. Spector, MD scientific knowledge and their effect on management of drug Department of Medicine allergy. This document was written and reviewed by special- UCLA School of Medicine ists in the field of allergy and immunology and was exclu- Los Angeles, California sively funded by the 3 allergy and immunology organizations Stephen A. Tilles, MD noted above. Department of Medicine A Working Group chaired by Roland Solensky, MD,

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